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psnet.ahrq.gov/node/33883/psn-pdf
July 01, 2019 - Identifying the stakeholders and whether they understand what
you're talking about, so they can engage
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psnet.ahrq.gov/print/pdf/node/867461
January 31, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient and Family Engagement in Long
Term Care
Curated Library
Foundations
Long-term Care and Patient Safety
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024
A large and growing number of Americans require care in skilled nursin…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/primer/burnout
November 20, 2024 - Burnout
Citation Text:
Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Patient and Family Engagement in Long Term Care
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Created By: Lorri Zipperer, C…
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Delayed Recognition of a Positive Blood Culture
July 1, 2017
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - By identifying strengths, the opportunity exists for patients and families to learn, acquire information
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psnet.ahrq.gov/issue/2024-network-patient-safety-databases-chartbook-medication-and-other-substance-events
September 11, 2024 - Book/Report
2024 Network of Patient Safety Databases Chartbook: Medication and Other Substance Events.
Citation Text:
2024 Network Of Patient Safety Databases Chartbook: Medication And Other Substance Events. Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Pub. No. …
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psnet.ahrq.gov/issue/opioid-overdose
April 06, 2022 - Government Resource
Opioid Overdose.
Citation Text:
Opioid Overdose. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/data-docs
March 02, 2016 - Newspaper/Magazine Article
Data docs.
Citation Text:
Data docs. Wherry R.
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November 4, 2015
Wherry R.
…